Optimize Payment by Knowing When to Use Modifier -59 vs. -51

Modifier -59 (distinct procedural service) is often appended incorrectly or overlooked in favor of modifier -51 (multiple procedures). In the ob/gyn or any specialty setting, this can result in denied claims and lost revenue.

Modifier -59 essentially unbundles procedures. It is the coders and the physicians way of saying to the carrier, Yes, I know procedure B is normally bundled into procedure A, but take a look at this case, which justifies additional reimbursement for additional work done. If the physician can show through his or her operative notes that a distinct procedural service occurred, many commercial carriers will honor the modifier and pay for the additional procedure.

Dont Confuse -59 With Multiple Procedures

Modifier -59 is easily confused with -51. The difference is that -51 is used for procedures that are not normally bundled, but are stand-alone procedures. The -51 modifier simply acknowledges to the carrier that you performed multiple services on the same day and that you anticipate a reduction in fees (generally 50 percent on the second procedure, more on subsequent procedures). Use modifier -59 when you are trying to say that the additional procedure (which is normally an integral part of another procedure performed that day) was distinct and should be allowed to be billed and paid separately.

CPTs rules on modifiers clarify the distinction between the two. Modifier -59 is appended when the procedure identified by CPT as a separate procedure involves:

A different session or patient encounter;

A different procedure or surgery;

A different site or organ system;

A separate incision/excision;

A separate lesion; or

Treatment of a separate injury (or area of injury in extensive injuries).

Modifier -51 indicates multiple procedures that would not normally be bundled together anyway, and is used when:

Multiple medical procedures are performed at the same session by the same provider;

Multiple, related operative procedures are performed at the same session by the same provider;

Operative procedures are performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy; or

A combination of medical and operative procedures is performed at the same session by the same provider.

An Ob/gyn Vignette Using -59

The following ob/gyn scenario, offered by Melanie Witt, RN, CPC, MA, an independent ob-gyn coding educator, illustrates the proper use of modifier -59.